The country may be battling the largest outbreak of cholera barely a month after the Nigerian Centre for Disease Control, NCDC, said it had contained the outbreak.

Fear is growing as many Nigerians pay with their lives. Almost on daily basis, in the last one week, the media has reported the death of one or more Nigerian due to cholera.

Many states are affected. The fear that the situation may get worse may not be unconnected with the fact that the rains, a factor in the spread, are still much around and every part of Nigeria is a potentially fertile ground for cholera outbreak.

There have been conflicting figures of cholera cases but the latest Epidemiology Summary Sunday Vanguard obtained from the NCDC shows that no fewer than 434 Nigerians have lost their lives to the outbreak and 23,893 suspected cases recorded between January and August 2018.

The reported cases were from 168 local governments in 17 states of Adamawa, Anambra, Bauchi, Borno, Ebonyi, Gombe, Jigawa, Kaduna, Kano, Katsina, Kogi, Nasarawa, Niger, Plateau, Yobe, Sokoto and Zamfara as well as the FCT since the beginning of the year.

According to the Epidemiology Summary, in the week of 34 (21- 26 August,) about 228 new suspected cases were reported in Zamfara (105), Kano (96) and Katsina (27), with 9 deaths (5 in Zamfara and 4 in Kano).

Also, update from the World Health Organisation, WHO, and other partners on Echo Daily reveals that, with such suspected cases, including deaths, the figure has exceeded the combined number of cases recorded from 2015 to 2017.

The WHO report traces the huge number of cases to factors including limited access to water and sanitation infrastructure, poor hygiene practices and harsh weather conditions.

Fresh in the minds of Nigerians is the latest outbreak of cholera in Borno and Kaduna states. In Borno, 14 people were killed by the disease with over 380 hospitalised in the past week.

The state Commissioner for Health, Haruna Mshelia, who confirmed the report, said as of September 5, 2018, a total of 380 cases of suspected cholera had been reported with 14 deaths.

Mshelia said most of the suspected cases and deaths occurred in camps for displaced people in Maiduguri, while other victims were from neighbouring districts on the outskirts of the state capital.

He, however, disclosed that the state government and non-governmental organisations were working to contain the outbreak which had spread to eight local governments across Borno.

In Katsina, 18 people were feared dead in Charanchi Local Government Area and 24 hospitalised following the suspected outbreak of cholera which earlier claimed 47 lives in the LGA.

Media reports also show that the outbreak had earlier claimed 29 lives in about 181 cases recorded in Funtua, Kusada, Kaita, Ingawa, Katsina and Kankia council areas of the state.

Some of the communities affected include Malole and Manye where eight persons tested positive and were reportedly responding to treatment at the Comprehensive Healthcare Clinic in Charanchi.

These fresh outbreaks have created panic among Nigerians particularly residents of affected areas.

What does this development mean for Nigeria? Are there lessons to be learned?

According to experts, cholera thrives in a dirty environment and poor handling of faeces remains a major contributor to its contamination of foods and fruits.

For instance, open defecation practice is commonplace in Nigeria. This is compounded by the fact that the bacteria causing cholera – Vibrio cholerae – multiplies in the intestine and can remain there for several years. Usually, faeces of a carrier are usually contaminated. This practice offers an opportunity to release the bacterium into the environment. Unfortunately, through this source, contamination of farm products and farm products are common. If not properly handled, humans are also infected by the contaminated food.

The trend is also compounded by recent flooding across the country which can wash the bacterium into various sources of drinking water in the communities.

Government response

Meanwhile, the Minister of Health, Prof Isaac Adewole, has announced plans by the Federal Government to come up with a robust plan to banish cholera in the next five years.

Also speaking, the Chief Executive of NCDC, Dr. Chikwe Ikpeazu, who believed that epidemic prone diseases seem to be on the rise in Nigeria, said that the Centre had increased its response activities being coordinated by the Emergency Operation Committee, EOC, in collaboration with National Primary Health Care Development Agency, NPHCDA, Federal Ministry of Water Resources (FMWR), WHO, UNICEF and MSF among others.

In the Centre’s Epidemiology Summary, he explained that active case search was ongoing in states with active transmission while daily follow-up with all affected and weekly follow-up with non-reporting states via calls were ongoing. Also, cases were being treated at designated health facilities or Cholera Treatment Centres (CTCs) in affected states.

The NCDC also identified delay in receiving line list from some states or late submission of line list and poor outbreak response capacity in newly affected areas as some of their challenges in their response efforts.

Why cholera outbreak persists

However, despite these efforts, the outbreak has persisted. Furthermore, health watchers believe that, unlike the response to Ebola outbreak, government has failed to accord necessary attention to cholera which has been seen as a key indicator of lack of social development.

They are of the opinion that if the cause of the frequent occurrence of cholera in the northern part of the country was due to their dependence on hand dug wells and contaminated ponds for their drinking water needs, efforts should have been made to provide Nigerians with good drinking water in the 21st century.

According to a family health physician, Dr. Ibrahim Ogunbi, cholera is an intestinal infection characterised by watery stool and diarrhea and caused by the Vibrio cholerae, a bacterium, which releases toxins in the human intestine. This toxin is said to activate excess secretion of water from the intestinal lumen that often leads to severe dehydration and sometimes death.

The major reasons for the consistent outbreak of cholera in the country, Ogunbi explained, remain poverty, dirty environment and lack of social amenities like water.

“Many Nigerians have no access to safe water. Many depend on dug well for their water supply which is mostly contaminated by heavy flood which can cause the movement of water from one place to another contaminating the source of water. It is also known that flooding can cause septic tanks to contaminate water sources. This is why cholera outbreak increases during the rainy season,” he noted.

Studies have shown that about 75 percent of people infected with cholera do not develop any symptoms, although the bacteria are present in their faeces for 7-14 days after which the infection is shed back into the environment, potentially infecting other people. Among people who develop symptoms, 80 percent have mild or moderate symptoms, while around 20 percent develop acute watery diarrhea with severe dehydration.

In severe infections, more than one quarter of water and salts is lost per hour. The stool looks gray and has flecks of mucus in it – termed ‘rice water stool’. Within hours, dehydration can become severe, causing intense thirst, muscle cramps and weakness. Very little urine is produced and the eyes may become sunken, and the skin on the fingers may become much wrinkled. If dehydration is not treated, loss of water and salts can lead to kidney failure, shock, coma and death. In people who survive, symptoms usually subside in 3 to 6 days. Most people are free of the bacteria in two weeks. The bacteria remain in a few people indefinitely without causing symptoms.

Ogunbi maintained that cholera outbreak can only occur when there are significant breaches in the water, sanitation and hygiene infrastructure used by groups of people, permitting large-scale exposure to food or water contaminated with Vibrio-cholera organisms; and cholera must be present in the population.

“Cholera has been proven to be transmitted through the fecal-oral route via contaminated food, carriers of the infection and inadequate sanitary conditions of the environment. Another factor that may greatly contribute to the risk of cholera transmission is population movement which enhances the spread of the infectious agent to others and to different sites”, he added.

Sadly, conditions such as the disruption in water supply, poor basic sanitation and poor hygiene have persisted and have contributed greatly to cholera infections in Nigeria.

Reducing drivers of cholera outbreak

To reduce the drivers of the outbreaks in future, Ogunbi said the country must tackle the factors that cause flooding. It must also take decisive steps to relocate residents from flood-prone areas and improve on environmental sanitation and public health campaigns.

“Educating our people first about cholera is important. There is a need for them to understand the symptoms and seek medical help on time”, the expert said.

He also called on government to investigate outbreaks and find a lasting solution to the causes.

Ogunbi said to break the chain of outbreaks, there is a need for the ministries of health to establish treatment centres in areas where the outbreaks are common.

“There is a need for Nigeria to pay attention to a cleaner environment. There is also the need for government to make available vaccination for cholera. Government should assist in providing vaccines to those areas that are affected so that they don’t spread the disease. We have the oral vaccination that can be given. Treatment should also be free”, he stressed.

Studies also show that eradicating cholera and other diarrhoeal diseases in Nigeria will require a multi-sectoral approach. The ministries of water resources, rural development, urban planning and health must contribute, and government must show the political will to invest in infrastructure as well as health sector development.

History of outbreaks

Statistics show that the world has witnessed eight pandemics of cholera.

During the 19th century, cholera spread across the world from its original reservoir in Bangladesh and West Bengal, claiming millions of lives across all continents most especially in Africa and Asia.

Cholera is now endemic in many countries and recent studies have indicated that global warming creates a favourable environment for the bacteria.

The emergence of cholera in Nigeria was evident in 1970 and was re-introduced in 1991.

During the last two decades, three major epidemics have occurred: 1992, 1995-1996, and 1997.

Northern Nigeria has been known to be endemic for cholera infection.

In 1982, Katsina was affected by an outbreak of gastroenteritis associated with Vibrio- cholera serotype. The 1996 outbreak reported in Kano affected 1, 384 individuals with a fatality.

In Abeokuta, South-western Nigeria, between November 2005 and January 2006, 11 deaths from the 115 cases with case fatality rate of 9.6 percent were reported from a cholera outbreak.

The 2010 outbreak was projected as the worst in Nigeria since 1991 with the highest case-fatality rates. The Nigerian states with case fatality rates (CFRs) in the 2010 outbreak include Plateau, Kaduna and Katsina states at 23.0%, 9.0%, and 7.6% respectively.

In the last quarter of 2009, it was speculated that more than 260 people died of cholera in four northern states with over 96 people in Maiduguri, Biu, Gwoza, Dikwa and Jere council areas of Bauchi State.

Despite this long experience with cholera, an understanding of the epidemiology of the disease aiding its persistence in outbreak situations is still lacking.

Health watchers say cholera has a clear link to poverty and lack of basic amenities, hence the need for the provision of good water sources. They point out that tackling these factors that lead to frequency and severity of the disease, as well as its epidemic potential, will help contain the outbreak and its spread.